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Frommelt PC, Minich LL, Trachtenberg FL, Altmann K, Camarda J, Cohen MS, Colan SD, Dragulescu A, Frommelt MA, Johnson TR, Kovalchin JP, Lin L, Mahgerefteh J, Nutting A, Parra DA, Pearson GD, Pignatelli R, Sachdeva R, Soriano BD, Spurney C, Srivastava S, Statile CJ, Stelter J, Stylianou M, Thankavel PP, Tierney ES, van der Velde ME, Lopez L. Challenges With Left Ventricular Functional Parameters: The Pediatric Heart Network Normal Echocardiogram Database. J Am Soc Echocardiogr 2019; 32:1331-1338.e1. [PMID: 31351792 DOI: 10.1016/j.echo.2019.05.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 05/20/2019] [Accepted: 05/21/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND The reliability of left ventricular (LV) systolic functional indices calculated from blinded echocardiographic measurements of LV size has not been tested in a large cohort of healthy children. The objective of this study was to estimate interobserver variability in standard measurements of LV size and systolic function in children with normal cardiac anatomy and qualitatively normal function. METHODS The Pediatric Heart Network Normal Echocardiogram Database collected normal echocardiograms from healthy children ≤18 years old distributed equally by age, gender, and race. A core lab used two-dimensional echocardiograms to measure LV dimensions from which a separate data coordinating center calculated LV volumes and systolic functional indices. To evaluate interobserver variability, two independent expert pediatric echocardiographic observers remeasured LV dimensions on a subset of studies, while blinded to calculated volumes and functional indices. RESULTS Of 3,215 subjects with measurable images, 552 (17%) had a calculated LV shortening fraction (SF) < 25% and/or LV ejection fraction (EF) < 50%; the subjects were significantly younger and smaller than those with normal values. When the core lab and independent observer measurements were compared, individual LV size parameter intraclass correlation coefficients were high (0.81-0.99), indicating high reproducibility. The intraclass correlation coefficients were lower for SF (0.24) and EF (0.56). Comparing reviewers, 40/56 (71%) of those with an abnormal SF and 36/104 (35%) of those with a normal SF based on core lab measurements were calculated as abnormal from at least one independent observer. In contrast, an abnormal EF was less commonly calculated from the independent observers' repeat measures; only 9/47 (19%) of those with an abnormal EF and 8/113 (7%) of those with a normal EF based on core lab measurements were calculated as abnormal by at least one independent observer. CONCLUSIONS Although blinded measurements of LV size show good reproducibility in healthy children, subsequently calculated LV functional indices reveal significant variability despite qualitatively normal systolic function. This suggests that, in clinical practice, abnormal SF/EF values may result in repeat measures of LV size to match the subjective assessment of function. Abnormal LV functional indices were more prevalent in younger, smaller children.
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Affiliation(s)
| | | | | | - Karen Altmann
- Columbia University Medical Center, New York, New York
| | | | - Meryl S Cohen
- Children's Hospital of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | | | | | | - Lina Lin
- New England Research Institute, Boston, Massachusetts
| | | | - Arni Nutting
- Medical University of South Carolina, Charleston, South Carolina
| | - David A Parra
- Vanderbilt Medical Center (D.A.P.), Nashville, Tennessee
| | - Gail D Pearson
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | | | - Ritu Sachdeva
- Emory University School of Medicine, Atlanta, Georgia
| | | | | | | | | | | | - Mario Stylianou
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | | | | | | | - Leo Lopez
- Stanford University, Palo Alto, California
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9
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Selamet Tierney ES, Hollenbeck-Pringle D, Lee CK, Altmann K, Dunbar-Masterson C, Golding F, Lu M, Miller SG, Molina K, Natarajan S, Taylor CL, Trachtenberg F, Colan SD. Reproducibility of Left Ventricular Dimension Versus Area Versus Volume Measurements in Pediatric Patients With Dilated Cardiomyopathy. Circ Cardiovasc Imaging 2017; 10:CIRCIMAGING.116.006007. [PMID: 29133477 DOI: 10.1161/circimaging.116.006007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 09/26/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Multiple echocardiographic methods are used to measure left ventricular size and function. Clinical management is based on individual evaluations and longitudinal trends. The Pediatric Heart Network VVV study (Ventricular Volume Variability) in pediatric patients with dilated cardiomyopathy has reported reproducibility of several of these measures, and how disease state and number of beats impact their reproducibility. In this study, we investigated the impact of observer and sonographer variation on reproducibility of dimension, area, and volume methods to determine the best method for both individual and sequential evaluations. METHODS AND RESULTS In 8 centers, echocardiograms were obtained on 169 patients prospectively. During the same visit, 2 different sonographers acquired the same imaging protocol on each patient. Each acquisition was analyzed by 2 different observers; first observer analyzed the first acquisition twice. Intraobserver, interobserver, interacquisition, and interobserver-acquisition (different observers and different acquisition) reproducibility were assessed on measurements of left ventricular end-diastolic dimension, area, and volume. Left ventricular shortening fraction, ejection fraction, mass, and fractional area change were calculated. Percent difference was calculated as (interobservation difference/mean)×100. Interobserver reproducibility for both acquisitions was better for both volume and dimension measurements (P≤0.002) compared with area measurements, whereas intraobserver, interacquisition (for both observers), and interobserver-acquisition reproducibilities (for both observer-acquisition sets) were best for volume measurements (P≤0.01). Overall, interobserver-acquisition percent differences were significantly higher than interobserver and interacquisition percent differences (P<0.001). CONCLUSIONS In pediatric patients with dilated cardiomyopathy, compared with dimension and area methods, left ventricular measurements by volume method have the best reproducibility in settings where assessment is not performed by the same personnel. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT00123071.
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Affiliation(s)
- Elif Seda Selamet Tierney
- From the Department of Pediatrics, Stanford University, Palo Alto, CA (E.S.S.T.); New England Research Institutes, Watertown, MA (D.H.-P., M.L., F.T.); Department of Pediatrics, St. Louis Children's Hospital, Washington University, MO (C.K.L.); Department of Pediatrics, New York Presbyterian Medical Center, Columbia University (K.A.); Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA (C.D.-M., S.D.C.); Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada (F.G.); Department of Pediatrics, Duke University School of Medicine, Durham, NC (S.G.M.); Department of Pediatrics, Primary Children's Medical Center, University of Utah School of Medicine, Salt Lake City (K.M.); Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, CA (S.N.); and Department of Pediatrics, Medical University of South Carolina, Children's Hospital of South Carolina, Charleston (C.L.T.).
| | - Danielle Hollenbeck-Pringle
- From the Department of Pediatrics, Stanford University, Palo Alto, CA (E.S.S.T.); New England Research Institutes, Watertown, MA (D.H.-P., M.L., F.T.); Department of Pediatrics, St. Louis Children's Hospital, Washington University, MO (C.K.L.); Department of Pediatrics, New York Presbyterian Medical Center, Columbia University (K.A.); Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA (C.D.-M., S.D.C.); Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada (F.G.); Department of Pediatrics, Duke University School of Medicine, Durham, NC (S.G.M.); Department of Pediatrics, Primary Children's Medical Center, University of Utah School of Medicine, Salt Lake City (K.M.); Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, CA (S.N.); and Department of Pediatrics, Medical University of South Carolina, Children's Hospital of South Carolina, Charleston (C.L.T.)
| | - Caroline K Lee
- From the Department of Pediatrics, Stanford University, Palo Alto, CA (E.S.S.T.); New England Research Institutes, Watertown, MA (D.H.-P., M.L., F.T.); Department of Pediatrics, St. Louis Children's Hospital, Washington University, MO (C.K.L.); Department of Pediatrics, New York Presbyterian Medical Center, Columbia University (K.A.); Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA (C.D.-M., S.D.C.); Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada (F.G.); Department of Pediatrics, Duke University School of Medicine, Durham, NC (S.G.M.); Department of Pediatrics, Primary Children's Medical Center, University of Utah School of Medicine, Salt Lake City (K.M.); Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, CA (S.N.); and Department of Pediatrics, Medical University of South Carolina, Children's Hospital of South Carolina, Charleston (C.L.T.)
| | - Karen Altmann
- From the Department of Pediatrics, Stanford University, Palo Alto, CA (E.S.S.T.); New England Research Institutes, Watertown, MA (D.H.-P., M.L., F.T.); Department of Pediatrics, St. Louis Children's Hospital, Washington University, MO (C.K.L.); Department of Pediatrics, New York Presbyterian Medical Center, Columbia University (K.A.); Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA (C.D.-M., S.D.C.); Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada (F.G.); Department of Pediatrics, Duke University School of Medicine, Durham, NC (S.G.M.); Department of Pediatrics, Primary Children's Medical Center, University of Utah School of Medicine, Salt Lake City (K.M.); Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, CA (S.N.); and Department of Pediatrics, Medical University of South Carolina, Children's Hospital of South Carolina, Charleston (C.L.T.)
| | - Carolyn Dunbar-Masterson
- From the Department of Pediatrics, Stanford University, Palo Alto, CA (E.S.S.T.); New England Research Institutes, Watertown, MA (D.H.-P., M.L., F.T.); Department of Pediatrics, St. Louis Children's Hospital, Washington University, MO (C.K.L.); Department of Pediatrics, New York Presbyterian Medical Center, Columbia University (K.A.); Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA (C.D.-M., S.D.C.); Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada (F.G.); Department of Pediatrics, Duke University School of Medicine, Durham, NC (S.G.M.); Department of Pediatrics, Primary Children's Medical Center, University of Utah School of Medicine, Salt Lake City (K.M.); Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, CA (S.N.); and Department of Pediatrics, Medical University of South Carolina, Children's Hospital of South Carolina, Charleston (C.L.T.)
| | - Fraser Golding
- From the Department of Pediatrics, Stanford University, Palo Alto, CA (E.S.S.T.); New England Research Institutes, Watertown, MA (D.H.-P., M.L., F.T.); Department of Pediatrics, St. Louis Children's Hospital, Washington University, MO (C.K.L.); Department of Pediatrics, New York Presbyterian Medical Center, Columbia University (K.A.); Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA (C.D.-M., S.D.C.); Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada (F.G.); Department of Pediatrics, Duke University School of Medicine, Durham, NC (S.G.M.); Department of Pediatrics, Primary Children's Medical Center, University of Utah School of Medicine, Salt Lake City (K.M.); Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, CA (S.N.); and Department of Pediatrics, Medical University of South Carolina, Children's Hospital of South Carolina, Charleston (C.L.T.)
| | - Minmin Lu
- From the Department of Pediatrics, Stanford University, Palo Alto, CA (E.S.S.T.); New England Research Institutes, Watertown, MA (D.H.-P., M.L., F.T.); Department of Pediatrics, St. Louis Children's Hospital, Washington University, MO (C.K.L.); Department of Pediatrics, New York Presbyterian Medical Center, Columbia University (K.A.); Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA (C.D.-M., S.D.C.); Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada (F.G.); Department of Pediatrics, Duke University School of Medicine, Durham, NC (S.G.M.); Department of Pediatrics, Primary Children's Medical Center, University of Utah School of Medicine, Salt Lake City (K.M.); Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, CA (S.N.); and Department of Pediatrics, Medical University of South Carolina, Children's Hospital of South Carolina, Charleston (C.L.T.)
| | - Stephen G Miller
- From the Department of Pediatrics, Stanford University, Palo Alto, CA (E.S.S.T.); New England Research Institutes, Watertown, MA (D.H.-P., M.L., F.T.); Department of Pediatrics, St. Louis Children's Hospital, Washington University, MO (C.K.L.); Department of Pediatrics, New York Presbyterian Medical Center, Columbia University (K.A.); Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA (C.D.-M., S.D.C.); Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada (F.G.); Department of Pediatrics, Duke University School of Medicine, Durham, NC (S.G.M.); Department of Pediatrics, Primary Children's Medical Center, University of Utah School of Medicine, Salt Lake City (K.M.); Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, CA (S.N.); and Department of Pediatrics, Medical University of South Carolina, Children's Hospital of South Carolina, Charleston (C.L.T.)
| | - Kimberly Molina
- From the Department of Pediatrics, Stanford University, Palo Alto, CA (E.S.S.T.); New England Research Institutes, Watertown, MA (D.H.-P., M.L., F.T.); Department of Pediatrics, St. Louis Children's Hospital, Washington University, MO (C.K.L.); Department of Pediatrics, New York Presbyterian Medical Center, Columbia University (K.A.); Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA (C.D.-M., S.D.C.); Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada (F.G.); Department of Pediatrics, Duke University School of Medicine, Durham, NC (S.G.M.); Department of Pediatrics, Primary Children's Medical Center, University of Utah School of Medicine, Salt Lake City (K.M.); Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, CA (S.N.); and Department of Pediatrics, Medical University of South Carolina, Children's Hospital of South Carolina, Charleston (C.L.T.)
| | - Shobha Natarajan
- From the Department of Pediatrics, Stanford University, Palo Alto, CA (E.S.S.T.); New England Research Institutes, Watertown, MA (D.H.-P., M.L., F.T.); Department of Pediatrics, St. Louis Children's Hospital, Washington University, MO (C.K.L.); Department of Pediatrics, New York Presbyterian Medical Center, Columbia University (K.A.); Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA (C.D.-M., S.D.C.); Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada (F.G.); Department of Pediatrics, Duke University School of Medicine, Durham, NC (S.G.M.); Department of Pediatrics, Primary Children's Medical Center, University of Utah School of Medicine, Salt Lake City (K.M.); Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, CA (S.N.); and Department of Pediatrics, Medical University of South Carolina, Children's Hospital of South Carolina, Charleston (C.L.T.)
| | - Carolyn L Taylor
- From the Department of Pediatrics, Stanford University, Palo Alto, CA (E.S.S.T.); New England Research Institutes, Watertown, MA (D.H.-P., M.L., F.T.); Department of Pediatrics, St. Louis Children's Hospital, Washington University, MO (C.K.L.); Department of Pediatrics, New York Presbyterian Medical Center, Columbia University (K.A.); Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA (C.D.-M., S.D.C.); Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada (F.G.); Department of Pediatrics, Duke University School of Medicine, Durham, NC (S.G.M.); Department of Pediatrics, Primary Children's Medical Center, University of Utah School of Medicine, Salt Lake City (K.M.); Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, CA (S.N.); and Department of Pediatrics, Medical University of South Carolina, Children's Hospital of South Carolina, Charleston (C.L.T.)
| | - Felicia Trachtenberg
- From the Department of Pediatrics, Stanford University, Palo Alto, CA (E.S.S.T.); New England Research Institutes, Watertown, MA (D.H.-P., M.L., F.T.); Department of Pediatrics, St. Louis Children's Hospital, Washington University, MO (C.K.L.); Department of Pediatrics, New York Presbyterian Medical Center, Columbia University (K.A.); Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA (C.D.-M., S.D.C.); Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada (F.G.); Department of Pediatrics, Duke University School of Medicine, Durham, NC (S.G.M.); Department of Pediatrics, Primary Children's Medical Center, University of Utah School of Medicine, Salt Lake City (K.M.); Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, CA (S.N.); and Department of Pediatrics, Medical University of South Carolina, Children's Hospital of South Carolina, Charleston (C.L.T.)
| | - Steven D Colan
- From the Department of Pediatrics, Stanford University, Palo Alto, CA (E.S.S.T.); New England Research Institutes, Watertown, MA (D.H.-P., M.L., F.T.); Department of Pediatrics, St. Louis Children's Hospital, Washington University, MO (C.K.L.); Department of Pediatrics, New York Presbyterian Medical Center, Columbia University (K.A.); Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA (C.D.-M., S.D.C.); Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada (F.G.); Department of Pediatrics, Duke University School of Medicine, Durham, NC (S.G.M.); Department of Pediatrics, Primary Children's Medical Center, University of Utah School of Medicine, Salt Lake City (K.M.); Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, CA (S.N.); and Department of Pediatrics, Medical University of South Carolina, Children's Hospital of South Carolina, Charleston (C.L.T.)
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14
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Perin EC, Willerson JT, Pepine CJ, Henry TD, Ellis SG, Zhao DX, Silva GV, Lai D, Thomas JD, Kronenberg MW, Martin AD, Anderson RD, Traverse JH, Penn MS, Anwaruddin S, Hatzopoulos AK, Gee AP, Taylor DA, Cogle CR, Smith D, Westbrook L, Chen J, Handberg E, Olson RE, Geither C, Bowman S, Francescon J, Baraniuk S, Piller LB, Simpson LM, Loghin C, Aguilar D, Richman S, Zierold C, Bettencourt J, Sayre SL, Vojvodic RW, Skarlatos SI, Gordon DJ, Ebert RF, Kwak M, Moyé LA, Simari RD. Effect of transendocardial delivery of autologous bone marrow mononuclear cells on functional capacity, left ventricular function, and perfusion in chronic heart failure: the FOCUS-CCTRN trial. JAMA 2012; 307:1717-26. [PMID: 22447880 PMCID: PMC3600947 DOI: 10.1001/jama.2012.418] [Citation(s) in RCA: 335] [Impact Index Per Article: 27.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
CONTEXT Previous studies using autologous bone marrow mononuclear cells (BMCs) in patients with ischemic cardiomyopathy have demonstrated safety and suggested efficacy. OBJECTIVE To determine if administration of BMCs through transendocardial injections improves myocardial perfusion, reduces left ventricular end-systolic volume (LVESV), or enhances maximal oxygen consumption in patients with coronary artery disease or LV dysfunction, and limiting heart failure or angina. DESIGN, SETTING, AND PATIENTS A phase 2 randomized double-blind, placebo-controlled trial of symptomatic patients (New York Heart Association classification II-III or Canadian Cardiovascular Society classification II-IV) with a left ventricular ejection fraction of 45% or less, a perfusion defect by single-photon emission tomography (SPECT), and coronary artery disease not amenable to revascularization who were receiving maximal medical therapy at 5 National Heart, Lung, and Blood Institute-sponsored Cardiovascular Cell Therapy Research Network (CCTRN) sites between April 29, 2009, and April 18, 2011. INTERVENTION Bone marrow aspiration (isolation of BMCs using a standardized automated system performed locally) and transendocardial injection of 100 million BMCs or placebo (ratio of 2 for BMC group to 1 for placebo group). MAIN OUTCOME MEASURES Co-primary end points assessed at 6 months: changes in LVESV assessed by echocardiography, maximal oxygen consumption, and reversibility on SPECT. Phenotypic and functional analyses of the cell product were performed by the CCTRN biorepository core laboratory. RESULTS Of 153 patients who provided consent, a total of 92 (82 men; average age: 63 years) were randomized (n = 61 in BMC group and n = 31 in placebo group). Changes in LVESV index (-0.9 mL/m(2) [95% CI, -6.1 to 4.3]; P = .73), maximal oxygen consumption (1.0 [95% CI, -0.42 to 2.34]; P = .17), and reversible defect (-1.2 [95% CI, -12.50 to 10.12]; P = .84) were not statistically significant. There were no differences found in any of the secondary outcomes, including percent myocardial defect, total defect size, fixed defect size, regional wall motion, and clinical improvement. CONCLUSION Among patients with chronic ischemic heart failure, transendocardial injection of autologous BMCs compared with placebo did not improve LVESV, maximal oxygen consumption, or reversibility on SPECT. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00824005.
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Affiliation(s)
| | | | | | - Timothy D. Henry
- Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minnesota
- University of Minnesota School of Medicine, Minneapolis
| | | | - David X.M. Zhao
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | | | - Dejian Lai
- The University of Texas School of Public Health, Houston
| | | | | | - A. Daniel Martin
- University of Florida College of Public Health and Health Professions, Gainesville
| | | | - Jay H. Traverse
- Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minnesota
- University of Minnesota School of Medicine, Minneapolis
| | | | - Saif Anwaruddin
- Penn Heart and Vascular Hospital of the University of Pennsylvania, Philadelphia
| | | | | | | | | | - Deirdre Smith
- Texas Heart Institute, St. Luke’s Episcopal Hospital, Houston
| | | | - James Chen
- Texas Heart Institute, St. Luke’s Episcopal Hospital, Houston
| | | | - Rachel E. Olson
- Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | | | - Sherry Bowman
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Judy Francescon
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Sarah Baraniuk
- The University of Texas School of Public Health, Houston
| | | | | | | | | | | | | | | | | | | | | | - David J. Gordon
- National Heart, Lung and Blood Institute, Bethesda, Maryland
| | - Ray F. Ebert
- National Heart, Lung and Blood Institute, Bethesda, Maryland
| | - Minjung Kwak
- National Heart, Lung and Blood Institute, Bethesda, Maryland
| | - Lemuel A. Moyé
- The University of Texas School of Public Health, Houston
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